論防疫保險契約之理賠、調整與管制

A Research on COVID-19 Insurance Contract: Claims, Modification, and Regulation

嚴重特殊傳染性肺炎（COVID-19）對人類社會造成重大影響，對保險業也造成重大衝擊。在2022年間，臺灣以確診或隔離等為事故，提供住院、醫療或定額給付之防疫保險，產生諸多爭議。這除了涉及契約解釋以外，亦涉及政府指引或建議是否妥適之問題。本文乃依序對3個子題進行研究：防疫保險契約之理賠、調整與管制。首先分析本類契約之解釋與理賠問題，以明確契約效力範圍。再檢討本類保險契約有無主張給付不能、締約上過失或情事變更原則來調整之可能。第三則進一步檢驗政府對於防疫保險回應之妥適性並提出立法建議。本文發現，目前對防疫保險之多數解釋尚屬適當，且無法主張情事變更或給付不能，主管機關之指引或建議多未逾越適當範圍；但在居家照護比照住院等部分則較有疑問。雖然一般多將此類建議定性為行政指導，但本文認為仍應檢視是否與後續處分連結，且應符合一般法律原則與信賴保護，否則仍可能造成損失而有國家賠償之可能。在判斷是否對保險契約造成重大影響時，應得參考美國法之兩階段測試，並應考慮保險契約之本質。在立法上可參考美國法，明訂符合一定之特殊事由時，得對保險契約作暫時性之特定調整，以更妥適地因應未來之類似爭議。

The COVID-19 pandemic has had a profound impact on both human society and the insurance industry. Throughout 2022, numerous controversies emerged regarding COVID-19 insurance contracts triggered by confirmed cases or isolation, aimed at providing coverage for hospitalization, medical care, and fixed amounts. These controversies encompass not only issues related to the interpretation of contracts but also concerns about the appropriateness of guidance and instructions issued by authorities. This paper endeavors to explore three primary subtopics sequentially: claims, modifications, and regulations of COVID-19 insurance contracts. Firstly, the paper will commence by scrutinizing interpretation and claim issues to elucidate the scope of the contract's effectiveness. Secondly, it will proceed to examine potential modifications and remedial mechanisms of insurance contracts, such as impossibility of performance, culpa in contrahendo, and change of circumstances. Thirdly, the paper will delve into an assessment of the appropriateness of authority responses, followed by proposing recommendations to amend Taiwanese law.
This study concludes that the majority of the authority’s interpretations of insurance contracts are sound, and there exists no justifiable basis for contract modification. Consequently, the guidance and instructions provided by the authority are generally deemed appropriate. However, categorizing homecare as equivalent to hospitalization raises suspicions. Moreover, although such instructions are typically classified as administrative guidance, this paper contends that such categorization hinges on their relationship with subsequent administrative sanctions and their adherence to general legal principles and legitimate expectations. Failure to meet these criteria may potentially result in damages and liability. In evaluating the significance of damage to the contract, we recommend applying the two-prong test utilized in the United States and considering the nature of insurance contracts. Furthermore, we propose following the lead of the United States in amending relevant laws to incorporate special provisions allowing for the temporary modification of insurance contracts, thereby enabling more efficient handling of similar scenarios in the future.